Carcinoma in situ

What it means

"in situ" (from Latin for "in its place") An early stage cancer in which the cancerous
growth or tumour is still confined to the site from which it started.
It is non-invasive and does not penetrate more deeply into the tissue

Carcinoma-in-situ shall mean first ever diagnosis of a histologically proven, localized
pre-invasion lesion where cancer cells have not yet penetrated the basement membrane
or invaded (in the sense of infiltrating and / or actively destroying) the surrounding
tissues or stroma in any one of the following covered organ groups, and subject
to any classification stated:
FIGO refers to the staging method of the Federation Internationale de Gynecologie et d’Obstetrique

Breast, where the tumour is classified as Tis according to the TNM Staging method;

Corpus, uteri, vagina, vulva or fallopian tubes where the tumour is classified as
TIS according to the TNM Staging method or FIGO* Stage 0

Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy for Carcinoma-in-situ
of the Cervix/Carcinoma-in-situ of the Uterus/Carcinoma-in-situ of the Ovary

What it means

Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal
of entire uterus, the ovaries, fallopian tubes and the cervix. Here the procedure
is done for the carcinoma in situ of the cervix or uterus or ovary

The actual undergoing of a total abdominal hysterectomy and bilateral salpingo with
or without Oophorectomy due to CiS of the cervix/uterus/ovary/fallopian tube/vagina/vulva
(confirmed by histological evidence)

Surgery must be certified to be absolutely necessary by a specialist in the relevant
field.

-

Major Cancer

What it means

Cancer is a disease where normal cells change and grow in an abnormal way. If left
untreated, they can destroy surrounding healthy cells and eventually metastasize
i.e spread to other parts of the body. There are different types of cancer, which
vary widely in prognosis and treatment.

A malignant tumor characterized by the uncontrolled growth and spread of malignant
cells with invasion and destruction of normal tissues.

This diagnosis must be supported by histological evidence of malignancy. The term
cancer includes leukemia, lymphoma and sarcoma

All tumors which are histologically described as carcinoma in situ, benign, pre-malignant,
borderline malignant, low malignant potential, neoplasm of unknown behavior, or
non-invasive, including but not limited to: Carcinoma in situ of breasts, Cervical
dysplasia CIN-1, CIN -2 and CIN-3

Any non-melanoma skin carcinoma unless there is evidence of metastases to lymph
nodes or beyond

Malignant melanoma that has not caused invasion beyond the epidermis

All tumors of the prostate unless histologically classified as having a Gleason
score greater than 6 or having progressed to at least clinical TNM classification
T2N0M0

Angioplasty (stenting for Coronary Arteries)

What it means

Angioplasty opens blocked arteries and restores normal blood flow
It is done through a small puncture in a leg or arm artery and opens a clogged artery by inflating a tiny balloon in it
It is often combined with implantation of a stent to help open up the artery and decrease the chance of another blockage
The artery on which this procedure is done is the coronary artery, which supplies blood to the heart muscle

Coronary Angioplasty is defined as percutaneous coronary intervention by way of balloon angioplasty with or without stenting for treatment of the narrowing or blockage of minimum 50% of one or more major coronary arteries.

The intervention must be determined to be medically necessary by a cardiologist and supported by a coronary angiogram (CAG).

Intra Arterial investigative procedures and Diagnostic Angiography are excluded.
Coronary arteries herein refer only to Left Main Stem, Left Anterior Descending, Circumflex and Right Coronary Artery.

Angioplasty and stenting for carotid arteries

What it means

Angioplasty opens blocked arteries and restores normal blood flow
It is done through a small puncture in a leg or arm artery and opens a clogged artery by inflating a tiny balloon in it
It is often combined with implantation of a stent to help open up the artery and decrease the chance of another blockage
The artery on which this procedure is done is the carotid artery which is a major blood vessel in the neck that supply blood to the brain, neck, and face

Angioplasty and Stenting for Carotid Arteries shall mean the treatment of stenosis of 50% or above, as proven by angiographic evidence of one or more of carotid arteries.

Actual undergoing of an endovascular intervention such as angioplasty and/or stenting or atherectomy to alleviate the symptoms; and
The Diagnosis and medical necessity of the treatment must be confirmed by a Registered Medical Practitioner who is a specialist in the relevant field.

-

Endarterectomy

What it means

The carotid arteries are the main blood vessels that supply the head and neck.
Carotid endarterectomy is a surgical procedure to unblock a carotid artery that is stenosed (narrowed ).
The procedure is carried out to reduce risk of stroke

The actual undergoing of Endarterectomy of the carotid artery

Necessitated as a result of at least 80% narrowing of the carotid artery as diagnosed by an arteriography or any other appropriate diagnostic test that is available.

Endarterectomy of blood vessels other than the carotid artery is specifically excluded. Angioplasty and/or any other intra-arterial procedures are excluded.

Renal angioplasty

What it means

Angioplasty opens blocked arteries and restores normal blood flow
It is done through a small puncture in a leg or arm artery and opens a clogged artery by inflating a tiny balloon in it
It is often combined with implantation of a stent to help open up the artery and decrease the chance of another blockage
This procedure is done is done on the renal artery which is a major blood vessel that supply blood to the Kidney

The actual undergoing for the first time of Renal Artery Angioplasty or the insertion of a stent to correct the stenosis, of one or more renal arteries as shown by Angiographic or appropriate imaging evidence.

The revascularization must be considered medically necessary by an appropriate specialist.

Percutaneous procedures for heart valve repair or replacement

What it means

Heart valve disease occurs when a valve does not work correctly. A valve may not open all the way or a valve may have problems closing. If this happens, blood does not move through the heart's chambers the way it should
Instead of open heart surgery a catheter based procedure is used to repair or replace the malfunctioning valve
Repair means that the valve is mended to help it work better.
Replacement means the diseased valve is removed and a new valve is inserted in its place

Pericardectomy

What it means

The pericardium is a double-walled, membrane sac that surrounds the heart.
It contains a small amount of fluid that lubricates the heart during its normal pumping movements.
There are diseases and conditions in which the pericardium become stiff and calcified.
Pericardectomy is the surgical removal of the diseased pericardium.

The undergoing of a Pericardectomy through a median sternotomy or a thoracotomy approach for the treatment of constrictive pericarditis or recurrent pericarditis.

The surgical procedure must be certified to be absolutely necessary by a Specialist in cardiology.

-

Minimally invasive surgery for aortic aneurysm

What it means

Aorta is a major Blood vessel (artery) which carries oxygenated blood from the heart to the rest of the body.
Treatment may be needed to correct a weakening, narrowing or bulging in the aorta wall.
Procedures done to treat diseased aorta , which are minimally invasive ( procedures that are performed through small incision instead of one large opening )or using a catheter are included .
This procedure includes only the affected aorta in the chest and abdomen and not its branches

The actual undergoing of surgery via minimally invasive or intra-arterial techniques to repair or correct an aneurysm, narrowing, obstruction or dissection of the aorta

This must be evidenced by a cardiac echocardiogram or any other appropriate diagnostic test that is available and confirmed by a consultant cardiologist.

Aorta shall mean the thoracic and abdominal aorta but not its branches.

Infective endocarditis

What it means

Infective endocarditis is an inflammation of the inner lining of the heart (the endocardium) or the heart valves.
Endocarditis generally occurs when bacteria or other germs from another part of the body, spread through the bloodstream and attach to areas in the heart.
Left untreated, endocarditis can damage or destroy the heart valves and can lead to life-threatening complications

Inflammation of the inner lining of the heart caused by infectious organisms

All of the
following criteria are met:
Positive result of the blood culture proving presence of the infectious organism(s);
Presence of at least moderate heart valve incompetence (meaning regurgitant fraction of 20% or above) or moderate heart valve stenosis (resulting in heart valve area of 30% or less of normal value) attributable to Infective Endocarditis; and
The Diagnosis of Infective Endocarditis and the severity of valvular impairment are confirmed by a Registered Doctor who is a cardiologist.

-

Initial implantation of permanent pacemaker of the heart or implantable cardioverter-defibrillator (ICD)

What it means

A permanent pacemaker is a small device that is usually placed under the skin of the chest to help control abnormal heart rhythms that do not normalize with medication
An ICD is a battery-powered device placed under the skin that keeps track of the heart rate.
If an abnormal heart rhythm results in cardiac arrest (sudden , sometimes temporary cessation of heart 's function ) it is detected by the device which will deliver an electric shock to restore a normal heartbeat

Actual undergoing of insertion of a permanent cardiac pacemaker or cardiac defibrillator to correct serious cardiac arrhythmia which cannot be treated via other methods or the insertion of cardiac defibrillator to correct sudden loss of heart function with cessation of blood circulation around the body resulting in unconsciousness .
Insertion of Cardiac Defibrillator means surgical implantation of either Implantable Cardioverter- Defibrillator (ICD), or Cardiac Resynchronization Therapy with Defibrillator (CRT-D)

The insertion of a permanent Cardiac Pacemaker or Cardioverter-Defibrillator (ICD) must be certified to be absolutely necessary by a specialist in the relevant field.

Cardiac arrest secondary to alcohol or drug misuse will be excluded.

Surgery to place ventricular assist devices or total artificial hearts

What it means

A ventricular assist device is a mechanical device that is used to support completely or partially the function of a weakened heart
An artificial heart is a mechanical pump used to replace the function of a damaged heart either temporarily or as a permanent internal prosthesis

These devices are used when medical therapy has failed either as:
- Bridge to heart transplant I.e it can help the person survive until a donor heart is available or
- Destination therapy i.e when heart transplant is not an alternative , it provides long term support to patients with failing hearts

This is an open chest procedure for implantation of Left Ventricular Assist Device/Ventricular Assist Device as bridges to cardiac transplantation or destination therapy for long term use for the Refractory Heart Failure with reduced ejection fraction.

Reduced ejection fraction is as defined below: NYHA Class IV symptoms who failed to respond to optimal medical management for >= 45 of the past 60 days, or have been intra-aortic balloon pump dependent for 7 days, or IV inotrope dependent for 14 days.

Cardiomyopathy

What it means

Cardiomyopathy refers to diseases of the heart muscle.
The heart muscle becomes enlarged, thick or rigid.
As the condition worsens, the heart becomes weaker and less able to pump blood through the body and maintain a normal electrical rhythm.
Cardiomyopathy is a major cause of heart failure and one of the most common conditions leading to heart transplantation. The condition can also cause abnormal heart rhythms

An impaired function of the heart muscle, unequivocally diagnosed as Cardiomyopathy by a Registered Medical Practitioner who is a cardiologist, and which results in permanent physical impairment

Permanent physical impairment must be to the degree of New York Heart Association classification Class IV or its equivalent, for at least six (6) months based on the following classification criteria:
Class IV - Inability to carry out any activity without discomfort. Symptoms of congestive cardiac failure are present even at rest. With any increase in physical activity, discomfort will be experienced. The Diagnosis of Cardiomyopathy has to be supported by echographic findings of compromised ventricular performance.

Cardiomyopathy directly related to alcohol or drug abuse is excluded.

Major surgeries of aorta

What it means

Aorta is a major Blood vessel (artery) which carries oxygenated blood from the heart to the rest of the body.
Surgery may be needed to correct a weakening, narrowing or bulging in the aorta wall.
In this surgery part of the diseased artery wall is removed and replaced with a graft(i.e tissue from another site or synthetic material eg dacron is used )
This surgery includes only the affected aorta in the chest and abdomen and not its branches

The actual undergoing of surgery for a disease or injury of the aorta needing excision and surgical replacement of the diseased part of the aorta with a graft.

-

The term “aorta” means the thoracic and abdominal aorta but not its branches.
Surgery performed using only minimally invasive or intra-arterial techniques are excluded.

Open Chest CABG*

What it means

Coronary artery disease (CAD) is the narrowing of the coronary arteries – the blood vessels that supply oxygen and nutrients to the heart muscle.
CAD is caused by a build-up of fatty material within the walls of the arteries. This build-up narrows the inside of the arteries, limiting the supply of oxygen-rich blood to the heart muscle.
During CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery.
The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery.
This creates a new path for oxygen-rich blood to flow to the heart muscle.

The actual undergoing of heart surgery to correct blockage or narrowing in one or more coronary artery(s), by coronary artery bypass grafting done via a sternotomy (cutting through the breast bone) or minimally invasive keyhole coronary artery bypass procedures.

*Note: minimally invasive keyhole surgery also includes actual undergoing of Robotic cardiac surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked, by coronary artery bypass graft (CABG).

The diagnosis must be supported by a coronary angiography and the realization of surgery has to be confirmed by a cardiologist.

Angioplasty and/or any other intra-arterial procedures

Myocardial infarction (first heart attack – of specified severity)

What it means

Myo means " muscle " cardial means " Heart " , Infarction means "death of the heart tissue due to lack of blood supply "
Myocardial Infarction or heart attack occurs when blood flow to part of the heart muscle is blocked causing the heart muscle to become ischemic (does not get enough blood and oxygen). If the ischemia lasts long enough, there will be death of that area of the heart muscle.
Total or partial occlusion or spasm of one or more of the coronary arteries (blood vessels supplying the heart muscle) is one of the major causes of myocardial infarction.
This can cause various symptoms like chest pain, breathlessness, etc. and is associated with increase in cardiac enzymes (blood tests that indicate heart muscle damage) and typical ECG changes.

The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area.

The diagnosis for Myocardial Infarction should be evidenced by all of the following criteria:

A history of typical clinical symptoms consistent with the diagnosis of acute myocardial infarction (For e.g. typical chest pain)

Open heart replacement or repair of heart valves

What it means

Heart valves play a key role in ensuring that blood is pumped through the heart in one direction ,
Heart valve disease occurs when a valve does not work correctly. A valve may not open all the way or a valve may have problems closing. If this happens, blood does not move through the heart's chambers the way it should
During heart valve surgery, one or more of the diseased valves are repaired or replaced.
Repair means that the valve is mended to help it work better.
Replacement means the diseased valve is removed and a new valve is inserted in its place

The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s).

The diagnosis of the valve abnormality must be supported by an echocardiography and the realization of surgery has to be confirmed by a specialist medical practitioner

Catheter based techniques including but not limited to, balloon valvotomy / valvuloplasty are excluded.

Heart transplant

What it means

A heart transplant is surgery to remove a person's diseased heart and replace it with a healthy heart from a deceased donor.
Most heart transplants are done on patients who have end-stage heart failure.

The actual undergoing of a transplant of the Heart, that resulted from irreversible end-stage failure of the organ.

The undergoing of a transplant has to be confirmed by a specialist medical practitioner.